hall ticket no : 1601006120 GENERAL MEDICINE CASE Final practical exam LONG CASE A 46 yrs old male shortness of breath , bilateralpedal edema since 1week

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Case: 

46 yrs old male patient from bopparam labourer by occupation came to the opd with chief complaints of shortness of breath , bilateral pedal edema and decreased urine output since 1week 

History of presenting illness 

patient was apparently asymptomatic 1week ago and then he developed shortness of breath which was insidious onset gradually progressive (grade 2).

Bilateral pedal edema since 1 week pitting type. 

H/o decreased urine output since 1week.

No h/o of chest pain, cough, expectoration , hemoptysis, reccurent respiratory tract infections 

 No h/o palpitations, syncope, fever.

No h/o burning micturition , hematuria 

No history suggestive of hypo or hyperthyroidism 

Past history :: 

no similar complaints in the past 

known case of Hypertension since 4yrs( diagnosed when went to local rmp) and diabetes since 2yrs and is on regular medication.

Not a known case of asthma, tuberculosis and epilepsy. 

The patient is on dialysis maintenance  since 1 year 

Personal history :   

-consumes mixed diet 

-Normal appetite

-sleep-adequate

-Bowel and bladder are regular 

-He is a chronic alcoholic consumes 90 ml per day since 11yrs 

-No habit of  smoking  and tobacco and Pan chewing 

Family history:: 

No similar illness in the family 

Lower socioeconomic status 

no significant family history  

Treatment history :: medication for diabetics mellitus since 2yrs and hypertension since 4yrs 

General examination :

patient is conscious, coherent, cooperative , oriented to time place person comfortably lying on bed 

 moderately built and nourished.

 

pallor present 

edema present 

No signs of icterus cyanosis clubbing koilonychia ,generalised lymphadenopathy,

JVP- raised 

VITALS  pulse 78 /min no radio radial delay and radiofemoral dealy 

Blood pressure 150 /90 mmHg right arm supine position 

No significant postural fall 

Respiratory rate 20 cycles per minute 

Temperature afebrile 

Local examination of cardiovascular system ::

 

Inspection  : 

 shape of the chest normal , symmetrical  ,no deformity 

Trachea appear to be central ,no precordial bulge 

No visible impulses scars sinuses dilated veins in any part of the thorax 

Palpation : all inspectory findings confirmed by palpation   

Trachea is  central 

Apex beat is felt in 6th intercostal space 

Palpable P2 

No palpable  heart sounds and murmurs 

No palpable pericardial rub 

Percussion :  

Dull note is heard along the heart borders  

 Auscultation : S1 S2 heard no murmurs

Respiratory  system ::bilateral air entry present 

Normal vesicular breath sounds heard no added sounds 

Per abdomen :soft ,non tender, no organomegaly  ,no free fluid 

Bowel sounds heard 

Hernial orifices are normal 

CNS::  NO FOCAL NEUROLOGICAL DEFICIT 

INVESTIGATIONS 

HEMOGRAM : hemoglobin reduced 

Complete urine examination  proteinuria present albumin present 4+ sugar present in urine 

Renal function test  urea and creatinine  raised 

 

Liver function test 

ECG 

12 leaded ecg

Heart rate :  74bpm

Normal QR segment  

Normal PR segment 

Lead II  normal 

P wave 

Qrs complex 

ST segment 

T wave 

RR INTERVAL V1 to V6 for hypertrophy 

R wave is normal and progressive indicating no damage to coronary vessels and normal filling 

Chest x ray ::  

Ultrasound report.  Renal parenchymal disease grade II 

Provisional diagnosis ::  heart failure secondary to chronic kidney disease   

 Analysis  : heart failure due to fluid over load due to chronic kidney disease ,etiology is due to chronic hypertension and diabetes 

Treatment history ::     

TREATMENT: 

SALT AND FLUID RESTRICTION

TAB. NICARDIA 10MG T.I.D

TAB. LASIX 40MG B.D

TAB. ARKAMIN 100MG

TAB. UNIFER

CAPSULE. GEL CAL D3  

 46 yrs old male patient, labourer by occupation who is a k/c/o hypertension since 4 yrs, diabetic since 2 yrs and on dialysis maintainance since 1 yr came to the opd with chief complaints of shortness of breath , bilateral pedal edema and decreased urine output since 1week pitting type and with

H/o decreased urine output.

O/E pallor and edema present

Jvp is raised Apex beat felt at 6th intercostal space palpable P2 

Investigations findings:

1)Complete urine examination proteinuria present albumin present 4+ sugar present in urine

2)Renal function test urea and creatinine raised

3) Ecg:appears to be normal 

4)Ultrasound report.  

Renal parenchymal disease grade II

Provisional diagnosis:

heart failure secondary to chronic kidney disease